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Part 2 exam > Pain > Flashcards

Pain Flashcards

1
Q

What is pain?

A

unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

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2
Q

What is acute pain?

A

pain of recent onset and probable limited duration, usually with identifiable temporal and causal relationship to injury or disease

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3
Q

What is chronic pain?

A

pain that commonly persist beyond the time of healing of an injury and frequently with no clear identifiable cause

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4
Q

What are the pain pathways?

A

Sensors:
- C fibres (slow conducting, unmyelinated)
- A delta fibres (lightly myleinated faster conducting)

-Travel tp laminae I and II (Superficial dorsal horn) and wide dynamic range neurones in lamina V

Pathways:

Ascending:
- Spinoparabrachial pathway -> superficial dorsal horn -> affect
- Spinothalamic pathway -> deeper dorsal horn -> discrimination

  • Descending:
    • PAG -> RVM and LC –> inhibitory modulation of dorsal horn
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5
Q

What are some mantras with managing pain?

A

Pain is an individual, multifactorial experience influenced by culture, previous pain experiences, beliefs, mood and coping ability.

Ethical harnessing of placebo and minimisation of nocebo effects will improve response to pain management

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6
Q

What is the definition of chronic post surgical pain?

A

pain developing and persisting beyond the time expected for normal healing process (ICD-11 defines at least 3 months), after excluding pre-existing pain as well as infection and malignancy

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7
Q

What are the risk factors for chronic post surgical pain?

A

Patient: Catastrophising, anxiety, young adults, female, premorbid pain/hx chronic pain esp severe, depression, work cover,

Anaesthetic: poor post op pain control, single agent analgesia

Surgical: Repeat surgery, surgery with nerve injury, radiation, chemotherapy, prolonged surgery

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8
Q

What evidence is there for pharmacological agents in chronic post surgical pain?

A
  • Peri-op ketamine
  • Epidural for thoracotomy
  • Paravertebral for mastectomy
  • Gabapentinoids may prevent CPSP but not clear evidence
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9
Q

What agents have evidence for opioid sparing?

A
  • Gabapentin, pregabalin
  • NSAIDs
  • Lignocaine
  • Ketamine
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10
Q

What drugs are effective treatments for opioid induced pruritis?

A

-Naloxone
- Droperidol

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11
Q

What is the evidence for periop IV lignocaine?

A
  • Preventative analgesic effect in wide range of operations
  • extends >8 hrs after cessation of administration
  • Also effective in treatement of chronic neuropathic pain
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12
Q

What is the evidence for periop IV ketamine?

A
  • Reduces chronic post surgical pain
  • reduces opioid consumption
  • delatys time to firest analgesic request
  • Reduces PONV
  • Reduces development of Opioid induced hyperalgesia
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13
Q

What is the evidence for anti-depressants and anti-convuslants?

A
  • TCAs eg nortrip, amitrip have evidence for neuropathic pain, fibromyalgia and chronic headaches
  • Gabapentin and pregabalin have evidence in chronic neuropathic pain
  • Reduces post op pain, opioid use, vomiting, pruritis, urinary retention
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14
Q

What is the evidence for alpha 2 agonists?

A
  • Reduce post op pain and opioid consumption
  • Reduces nausea
  • Doesn’t prolong recovery time
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15
Q

What is the current evidence for cannabinoids?

A
  • no evidence in acute pain management
  • Mildly effective in chronic neuropathic pain
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16
Q

What is the evidence for calcitonin?

A
  • Reduces acute but not chronic phantom limb pain
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17
Q

What is the evidence for epidurals?

A
  • Better pain relief compared with opioids
  • For open AAA - decreased duration of intubation, reduces periop MI, reduces resp failure, reduces GI complications, reduces pain, reduces renal insufficiency
  • For thoracotomy: reduces risk of CPSP
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18
Q

What is the evidence for IT morphine?

A
  • Improves analgesia and is opioid sparing for up to 24hrs post abdominal surgery
  • increases rate of urinary retention and N+V vs systemic opioids in minor surgeries not major
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19
Q

What is the evidence for paravertebral blocks?

A
  • Better pain score compared with systemic analgesia for breast surgery
  • Comparable analgesia to thoracic epidural in thoracic surgery with less side effects
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20
Q

What is the evidence for LA infilitration in TKR and THR?

A
  • Nil benefit in total hip compared to multimodal
  • Better than multimodal in knees but no better than femoral nerve block
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21
Q

What is the evidence around PCAs?

A
  • Better analgesia and greater patient satisfaction compared with IV opioids
  • Higher consumption and more pruritis
  • Adding background rate increases resp depression without adding pain relief benefit
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22
Q

What is the evidence for analgesia in post-amputation pain?

A

-Morphine, gabapentin, ketamine is better than placebo
- Calcitonin reduces acute but not chronic
- Nerve sheath catheters provide post op analgesia but does not prevent post amputation pain
- Cortical re-organisation eg mirror therapy reduces chronic post ampuation pain

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23
Q

What is the evidence for analgesia in spinal surgery?

A

-peri-op gabapentinoids improves analgesia and reduces opioids
- effective for neuropathic pain

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24
Q

What is the evidence in lower back pain?

A

-staying active
- heat wrap therapy
- Behavioural therapy

25
Q

What is the evidence of herpes zoster pain?

A
  • antiviral within 72hrs of onset of rash accelerates resolution of acute pain, but doesn’t reduce post herpatic neuralgia indicence, severity and duration
  • immunisation of people >60 with VZV reduces indicdence of herpes zoster and post herpetic neuralgia
  • evidence for TCAs as first line along with simple analgesia and opioids
  • Second line being anti-convulsants, lignocaine patch
  • Patch is first line for post herpatic neuralgia
26
Q

What is the evidence for headaches?

A
  • paracetamol/NSAID for tension headache
  • Caffeine+ aspirin + paracetamol are better than paracetamol alone
  • Migraine treatment with paracetamol, NSAID, triptans
  • Cluster headache: parenteral triptans and high flow O2
  • Epidural blood patch for PDPH, ~20mls is optimal
27
Q

What is evidence in acute cancer pain?

A

-radiotherapy and bone targeting agents eg bisphosphonates, denosumab are effective for bony met pain
- neurolytic coeliac plexus block in pancreatic Ca lowers pain
- Patient education is important

28
Q

What is the evidence for labour epidural?

A
  • Superior to all other analgesics
  • Reduces risk of fetal acidosis
  • Increases duration of second stage and risk of instrumental delivery
  • Does not increase c section rate
29
Q

What is the evidence for post LSCS analgesia?

A
  • LA wound infiltration
  • TAP block only effective if no IT morph
  • Epidural/intrathecal morph
  • PCA
30
Q

What is the evidence for analgesia in the opioid tolerant patient?

A
  • Clonidine reduces opioid withdrawal symptoms
  • Remifentanil leads to opioid induced hyperalgesia, which is attenuated by propofol, ketamine and pregabalin
  • Ketamine improves post op pain
31
Q

What is neuropathic pain?

A

pain initiated or caused by a primary lesion or dysfunction in the nervous system

32
Q

What is pre-emptive analgesia?

A
  • an anti-nociceptive intervention started before a noxious stimulus
  • goal is to reduce the development of sub-acute or chronic pain by reducing or abolishing acute pain and thus preventing the changes associated with wind up
  • evidence for regional analgesia
  • Nil evidence for Opioids or NSAIDs
33
Q

What is preventive analgesia?

A

postoperative pain and/or analgesic consumption are reduced relative to another treatment/placebo/no treatment, as long as the effect is observed at a point in time that exceeds the expected duration of action of the intervention

34
Q

What is tolerance?

A

predictable physiological decrease in the effect of a drug over time so that a progressive increase in the amount of that drug is required to achieve the same effect

35
Q

What is dependence?

A

a physiological adaptation to a drug whereby abrupt discontinuation or reversal of that drug, or a sudden reduction in its dose, leads to a withdrawal syndrome

36
Q

What is FAS pain score?

A

A - Nil limitation
B - Some limitation
C- Severe limitation

37
Q

What is the FLACC scale?

A

Pain in paeds
Face
Legs
Activity
Cry
consolability

38
Q

What is evidence in burns analgesia?

A

-Multidisciplinary, multimodal
- Paracetamol, NSAIDS, opioids, ketamine, TCAs, Anticonvulsants, clonidine
- Opioids via PCA are effective

39
Q

What is the incidence of chronic post surgical pain?

A

Amputation 30-85%
Thoracotomy 5-65%
Mastectomy 11 - 57%

40
Q

What is the pathophysiology of chronic post surgical pain?

A
  • Peripheral sensitisation and inflammation
  • Wind up/NDMA triggering
  • Central sensitisation
  • Sympathetically maintained pain
  • Psychosocial factors contributing too
41
Q

What is the peri-operative management of chronic post surgical pain?

A
  • Starts at pre-assessment
  • Pre-emptive analgesia
  • Pre and post op plan involving patient
  • Managed psychological vulnerabilities
  • Regional techniques
  • Pregabalin/gabapentin and ketamine perioperatively
42
Q

What are types of post amputation pain syndromes?

A
  • Phantom pain (pain in missing limb)
  • Phantom sensation (feeling in missing limb)
  • Stump pain
43
Q

What are risk factors for post amputation pain syndromes?

A
  • Pre op pain levels
  • Pre op chemo
  • Lesser in children
44
Q

What are causes for post amputation pain syndromes?

A
  • Neuroma (10%)
  • Muscle spasm (45%)
  • Cortical reorganisation (45%)
45
Q

What is the onset and duration of post amputation pain syndromes?

A
  • Within a week
  • If early and severe increased risk of longstanding severe pain
  • at 2 years 16% resolved, 37% decreased, 44% no change and 3% increased
  • 25% get it constantly, 25% daily, 16% weekly and 36% less often than weekly
46
Q

What is the evidence for continous nerve infusions for post amputation pain syndromes?

A
  • effective acute analgesia
  • Nil preventive effect on phantom limb pain
47
Q

What is the evidence for epidurals for post amputation pain syndromes?

A

reduces the incidence of severe phantom limb pain

48
Q

What reduces phantom limb pain?

A
  • calcitonin
  • morphine
  • Ketamine
  • Gabapentin
  • Amitriptyline
49
Q

What reduces stump pain?

A
  • Ketamine
  • Lignocaine
  • Tramadol
  • Amitriptyline
50
Q

What is post thoracotomy pain syndrome?

A
  • Pain for greater than 2 months post op
  • Secondary to trauma and fibrosis of intercostal nerves
  • Epidural reduces incidence
51
Q

What are the types of complex regional pain syndrome? (CRPS)

A

Type 1: syndrome that develops after an initiating noxious event

Type 2: syndrome that develops after a nerve injury

similar presentation:

  • spontaneous pain/alloyndia/hyperalagesia in a terrority not limited to a single nerve and is disproportionate to the inciting event
  • Evidence of oedema, skin blood flow abnormality, sweating
  • diagnosis of exclusion
52
Q

What is the management for complex regional pain syndrome?

A
  • MDT
  • Education
  • Analgesia: Simple analgesia, TCS, gabapentin, opioids, vitamin C, interventional such as nerve blockades, intrathecal catheters
  • Physiotherapy
  • Pschyology
53
Q

What are the changes with elderly patients and pain?

A
  • Higher incidence of comorbid diseases and medications
  • Age related changes in physiology, PK and PD
  • Altered response to pain
  • Difficulties with assessment of pain
54
Q

What are the time frames for NOACs prior to neuraxial techniques?

A

Apixaban: 72 hrs
Rivaroxaban: 72 hrs
Dabigitran: 5 days (can be shortened to 3 days if normal renal function and nil increased bleeding risk factors)

55
Q

What is the time frame for antiplatelets and neuraxial techniques?

A

Clopidogrel: 7 days
Prasugrel: 7 - 10 days
Ticagrelor: 7 days

56
Q

What is the time frame for warfarin and neuraxial techniques?

A

5 days and normal INR

57
Q

What is the time frame for clexane and heparin for neuraxial techniques and catheters?

A

Clexane (prophylactic): hold 12 hrs pre and 12 hrs post neuraxial
- can restart 4 hours after catheter removal (as long as 12 hrs since neuraxial)

Clexane (therapeutic): hold 24 hrs pre neuraxial, can restart 24hrs after low risk surgery, 48-72 hrs after high risk surgery

Heparin: 4-6 hrs pre neuraxial with normal coags

can restart 1 hr post neuraxial

58
Q

What is naltrexone?

A

long acting competetive opioid antagonist used for opioid and alcohol addiction

59
Q

What is the management of patients taking naltrexone peri-operatively?

A
  • They should stop it 72hrs pre op
  • They will become opioid sensitive post cessation so should aim to opioid spare and use judicious amounts of opioids with close monitoring

Part 2 exam (15 decks)

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